Provider Demographics
NPI:1629052584
Name:MILES, ELIZABETH ANN (RN FNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:MILES
Suffix:
Gender:F
Credentials:RN FNP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:STRAKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:180 JORDAN LN
Mailing Address - Street 2:
Mailing Address - City:LONGVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56655
Mailing Address - Country:US
Mailing Address - Phone:218-363-3300
Mailing Address - Fax:218-363-2233
Practice Address - Street 1:180 JORDAN LN
Practice Address - Street 2:LONGVILLE LAKES CLINIC
Practice Address - City:LONGVILLE
Practice Address - State:MN
Practice Address - Zip Code:56655
Practice Address - Country:US
Practice Address - Phone:218-363-3300
Practice Address - Fax:218-363-2233
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0992752363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN443000000Medicaid
MN500002637Medicare ID - Type Unspecified
MN443000000Medicaid